Instructions for Use of Consent to Medical Or Surgical Care and Treatment Form

INSTRUCTIONS FOR USE OF CONSENT TO MEDICAL OR SURGICAL CARE AND TREATMENT FORM

This consent form was developed in response to requests by Cooperative of American Physicians, Inc. (CAP) members and is intended as an aid in focusing the discussion between you and your patient. It is not required that you use this particular form. Neither this consent form, nor any other, should be viewed as a substitute for your personal sharing of information in discussions with your patient regarding the proposed procedure.

If you use this consent form, the following guidelines are suggested:

• Complete the consent form by making an entry in each blank section within the form. If the section is not applicable to the proposed procedure, enter the words “not applicable” or notation “N/A.”

• Present this form to the patient yourself – its completion and presentation should not be delegated to your nurse or office staff.

• Remind the patient to read the “Message to Patients About Medical/Surgical Risks” printed on the second page of the form.

• Have the patient, or if the patient is unable, the appropriate authorized person, sign and date (and insert the time) the consent form.

• File the original completed, signed and dated (with time inserted) form in the patient’s medical record, and give the patient a copy.

• Enter a brief note in the patient’s medical records stating that the risks, benefits, alternatives, and the consequences of not having the procedure were discussed with the patient and that the patient’s questions regarding the proposed procedure were answered.

• If the patient speaks a language other than English, the physician, the physician’s staff, or an adult friend or relative of the patient may translate the form for the patient. The translator should sign and date the form where indicated.

Please feel free to contact the Risk Management Department if you have any questions or comments concerning the form. Our toll-free telephone number is 800-252-7706.

CONSENT TO MEDICAL OR SURGICAL CARE AND TREATMENT

NOTE TO PATIENT: There are risks involved in any procedure or treatment. It is not possible to guarantee or give assurance of a successful result. It is important that you clearly understand and agree to the planned surgery or treatment.

I authorize Dr. and such physicians, associates, assistants and other personnel or the hospital or medical facility chosen by him or her to perform the following (IN MEDICAL TERMS KNOWN AS): ______(IN COMMON TERMS KNOWN AS): ______and/or to do any other procedures that in their judgment may be advisable to my well-being, including such procedures as are considered medically advisable to remedy conditions discovered during the above procedure. • GENERAL RISKS AND COMPLICATIONS. I am satisfied with my understanding of the more common risks and complications of the treatment or procedure which are described generally on the back of this form. These risks include the risk of bleeding, infection, pain, anesthesia risks and death. • SPECIFIC RISKS AND COMPLICATIONS. I am satisfied with my understanding of specific risks of this procedure or treatment including (Doctor to describe specific risks where applicable): ______• ALTERNATIVE METHODS OF TREATMENT. I am satisfied with my understanding of alternative procedures or treatments and their possible benefits and risks including (Doctor to describe specific alternative procedures and complications where applicable): ______• NO TREATMENT. I am satisfied with my understanding of the possible consequences, outcomes or risks if no treatment is rendered. • SECOND OPINION. I have been offered the opportunity to seek a second opinion concerning the proposed treatment or procedure. • ADDITIONAL OR DIFFERENT PROCEDURES DURING CARE AND TREATMENT. I understand that conditions may arise which are unforeseen at this time and that it may be necessary and advisable to perform operations and procedures different from, or in addition to, the procedure described. I authorize and consent to the performance of such additional or different operations and procedures as are considered necessary and advisable. • OTHER SERVICES. I consent to the performance of pathology and radiology services as needed and I further authorize the disposal of any severed tissue or member in accordance with customary hospital or medical facility practice. • PHOTOGRAPHY. I consent to the photographing, filming or videotaping of the treatment or procedure for educational or diagnostic use . • NO GUARANTEES. I understand there are risks involved in any procedure or treatment, and it is not possible to guarantee or give assurance of a successful result. • OTHER QUESTIONS. I am satisfied with my understanding of the nature of the procedure or treatments and all of my additional questions about the treatment or procedure have been answered.

I have read and been given a copy of this form.

DATE: ______TIME ______AM/PM PRINT PATIENT NAME: ______SIGNATURE: ______(PATIENT. PARENT OR LEGAL GUARDIAN)

TRANSLATED BY (IF APPLICABLE): ______PHYSICIAN: ______WITNESS: ______

PLEASE READ THE GENERAL INFORMATION ON BACK.

WHITE-Office Copy CANARY-Patient A MESSAGE TO PATIENTS ABOUT MEDICAL/SURGICAL RISKS

Medicine and surgery are generally safe, helpful and often lifesaving. However, medical or surgical procedures of any type involve the taking of risks, ranging from minor to serious (including the risk of death). It is important to be aware of the following possible risks before receiving the treatment you and your physician are planning. The following may be the reactions of your body to medical/surgical operations or procedures:

1 INFECTION: Invasion of tissue by bacteria or other germs occurs to some degree whenever a cut, incision or puncture is made. In most instances, through the natural defense mechanisms of the body, healing of the affected area occurs without difﬁculty. In some instances antibiotic medicines are prescribed and at times additional surgical measures may be necessary to combat infection.

2 HEMORRHAGE: The cutting of blood vessels causes bleeding and this occurs in every surgical incision. This bleeding is usually controlled without difficulty. At times, blood transfusions are required to replace blood loss. If blood transfusions are given, there are additional risks of liver inflammation, hepatitis, and the possibility of receiving Acquired Immune Deficiency Syndrome (AIDS). There is no absolutely reliable way to predict these unwanted reactions, some of which may be quite serious and even lead to death.

3 DRUG REACTIONS: Unexpected allergies, lack of proper response to medications or illness caused by the prescribed drugs are possibilities. It is important for you to inform your physician and your anesthesiologist or certiﬁed registered nurse anesthetist of any problem you or your family have had with reactions to drugs and which medications you have taken in the past six months, including over-the-counter drugs, especially aspirin.

4 ANESTHESIA REACTIONS: There may be unusual or unexpected responses to the gases, drugs or methods used to anesthetize you which can lead to difficulties with lung, heart or nerve function. Eating or drinking before anesthesia increases the risks of vomiting which may cause significant complications. Inform your anesthesiologist or certified registered nurse anesthetist of problems you and your family have had with anesthesia.

5 BLOOD VESSEL INFLAMMATION AND CLOTTING: It is impossible to predict the occurrence of blood vessel inﬂammation and clotting problems. If blood clots form, they can move from where they formed to other areas of the body and cause injury.

6 INJURY TO OTHER ORGANS: Because of the closeness of other organs to the area being operated on, there may be injury to other organs. The stress of surgery or the procedure may also harm other organ systems of the body.

7 OTHER RISKS: It is not possible to list all the possible risks and complications, and their variations, that may arise in any surgical operation or medical procedure. Each situation depends upon the purpose and nature of the operation or procedures. Your physician is willing to discuss further with you various details about other risks.

ALTERNATIVES TO TREATMENT

Although you and your doctor have decided upon this procedure, do not hesitate to discuss the reasons for the choice and the alternatives available for treatment of your condition. In addition, be sure to ask your doctor any other questions that you may have about your treatment.